Provider Demographics
NPI:1508592387
Name:ELLIS, EMILY JO (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JO
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:IA
Mailing Address - Zip Code:52585-0127
Mailing Address - Country:US
Mailing Address - Phone:641-799-9738
Mailing Address - Fax:
Practice Address - Street 1:801 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-3120
Practice Address - Country:US
Practice Address - Phone:319-984-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA170328363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner